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Shavon Walker in Newark, Calif., Thursday, June 21, 2012. Walker, 37, is a diabetic with asthma, high blood pressure and high cholesterol and worries about obtaining health insurance because of her pre-existing medical conditions. (Anda Chu/Staff)

No state has more at stake in the momentous — and imminent — U.S. Supreme Court decision on the Obama administration’s health care reform law than California.

The ruling could affect millions of its residents and determine whether the state receives billions in new federal revenue.

The full impact, of course, depends on how the justices rule, since they could throw out the law entirely, declare it all constitutional, or reject portions of it, such as mandated insurance for most Americans. Their ruling could come as soon as Monday.

But any decision striking down even part of the law will reach across California. “There’s no state in the nation that would be more dramatically affected than California,” said Anthony Wright, executive director of Health Access California, a consumer group.

California, which has nearly 7 million uninsured residents, has aggressively sought to implement the law, known as the Affordable Care Act.

For instance, it has extended coverage to more than 400,000 low-income adults in programs set up by 47 counties.

And it has placed 11,000 people in a new insurance pool for those whose health problems make it difficult, if not impossible, to obtain coverage.

If the law is struck down, California stands to lose nearly $9 billion a year in federal funds beginning in 2014 to expand Medi-Cal, the state’s version of the federal Medicaid program for the poor and disabled, the Kaiser Family Foundation has estimated.

California has passed legislation to implement some popular provisions of the Affordable Care Act, so those would continue even if the law is struck down. These include: allowing young adults to remain on their parents’ health insurance policies, up to age 26; banning insurers from rejecting children younger than 18 because of their health problems; and, beginning Sunday, requiring new health insurance policies to cover maternity services.

Pros and cons

Antioch resident Elizabeth Harris hopes the court upholds the law because she believes it will help her to get the surgery she needs for painfully severe back problems. The 53-year-old part-time home-care worker has no insurance.

A clinic told her to go to the county hospital emergency room, but she worried that she would receive a bill she could not pay. “So you’d rather stay with the pain,” she said.

Under the health reform law, Harris might be able to obtain coverage through the upcoming Medi-Cal expansion or by finding subsidized coverage in a marketplace — the California Health Benefit Exchange — that would open in 2014.

If the law is upheld, the state hopes to pre-enroll people in October 2013.

Supporters of the law argue the court should leave it untouched, saying it is clearly constitutional. They also point to support for popular consumer protections in the bill, including rebates on some insurance premiums, help for seniors who fall into a Medicare prescription drug coverage gap known as “the doughnut hole,” free annual wellness checkups for Medicare recipients and the elimination of lifetime caps on health benefits.

But critics view the health care law as more boondoggle than boon. They argue that it will drive up premiums and other health care costs, cause many employers to drop coverage, build up bureaucracy and result in people having less control over their options.

“The president thought by giving away all these freebies that this would make the bill popular,” said John Graham, director of health care studies for Pacific Research Institute, a San Francisco-based free-market think tank. “But when we look at it in aggregate, it’s a very socially irresponsible piece of legislation.”

Graham favors a free-market approach that he says gives consumers more power over health care decisions and spending.

If the court throws out the part of the law that requires most people to buy insurance, the Obama administration and others say the judges also should strike the requirement that insurers enroll people regardless of pre-existing health conditions beginning in 2014.

Without universal enrollment, insurers say it would be unfair to require them to accept all sick people. That would let healthy people put off getting insurance until they needed it, resulting in a smaller insurance pool with sicker people. That would be unsustainable and would drive up premiums, insurers say.

State’s alternatives

If the court rejects insurance mandates for all, California could enact its own mandate or adopt incentives and penalties that impel people to get insurance, said Marian Mulkey, director of health reform for the California HealthCare Foundation.

Newark resident Shavon Walker is among those who are following the decision closely. Losing the law “would really disappoint and scare me,” she said. The 37-year-old has diabetes, high blood pressure and other health problems. Although she has coverage through her husband’s job, she worries that if she loses that, no insurers will accept her because of her medical condition.

“What would we do for health care?” she asked. “Do free clinics become flooded with people like me?”

California programs that could be in jeopardy depending on the Supreme Court’s ruling include:Low-Income Health Program: More than 400,000 low-income, mostly childless adults covered by interim programs in 47 counties. They would be transferred to Medi-Cal when it expands under the national reform in 2014.

Pre-Existing Condition Insurance Plan: Coverage for nearly 11,000 people whose health problems make it difficult, if not impossible, to obtain insurance. Program would end in 2014 when insurers could no longer reject people based on their medical conditions.California Health Benefit Exchange: State plans to open a marketplace in 2014 where many consumers could choose a health plan and determine whether they qualify for subsidies. Pre-enrollment is to begin in October 2013.Insurance company rebates: Insurers that fail to spend at least 80 percent of premiums on medical care and quality improvement, rather than salaries and other administrative costs, must rebate the difference to customers. Nearly 1.9 million Californians will receive $73.9 million in rebates this summer, averaging $65 per family.

MEASURES THAT WILL STAND

Some consumer protections will continue no matter what the Supreme Court decides because California has passed laws requiring that:Young adults can remain on their parents’ health insurance policies up to age 26.Insurers can no longer reject children under age 18 because of their health problems.Beginning July 1, new health insurance policies must cover maternity services. Insurers can no longer cancel people’s coverage when they become ill because of unintentional misrepresentations on their applications.

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